If you are of a certain age the word ‘vertigo’ may bring to mind images of a terrified Jimmy Stewart and the luminous Kim Novak.

Perhaps the Golden Gate Bridge will also crowd into your memory, as will the name ‘Hitchcock.’ The film “Vertigo” was not a great success when it was first distributed and did not garner recognition at awards time. In the last decade, however, critics have begun referring to this movie as, at least, one of Alfred Hitchcock’s best with some unequivocally calling it his masterpiece.

Recently, I experienced unexplained vertigo, the medical condition, not the film, for the first time and learned a great many interesting things from the experience.

Vertigo has been recognized since antiquity. This is not that surprising since so many afflictions of mankind have been described in the writings of Hippocrates of Kos (460 – 375 BCE) and others of his time. Hippocrates described what seems to be vertigo as the “presage of disaster,” likely associating it with some developing circulatory event such as stroke or developing heart failure. Julius Caesar (101-44 BCE) is considered to have been epileptic but some scholars are convinced he actually suffered from vertigo. Archigenes (end of 1st C-beginning of 2nd) probably also described vertigo. Juvenal, the poet (1st C) described alcohol-induced vertigo as “… the roof spins around dizzy, the table dances, and every light is double.” Aretaeus of Cappadocia (2nd C), second to Hippocrates in renown, wrote: “If darkness possess the eyes, and if the head be whirled about with dizziness, and the ears ring as from the sound of rivers rolling along with a great noise, or like the wind when it roars among the sails … we call the affection ‘scotoma’ or ‘vertigo;’ a bad complaint indeed …”

In the 10th century, the great Persian physician and polymath Avicenna (980-1037) provided the most detailed account of vertigo ever written, attributing the disorder to a long list of unnatural causes, each having its own symptom (a symptom is something the patient experiences and is able to relate to the physician and a sign is an objective finding the physician can observe). Avicenna recommended specific therapy, details of which are not clear.

William Shakespeare (1564-1616) lived a relatively short life, yet his erudition and the depth and breadth of his knowledge are remarkable and mysterious. He did not have a university education but seemingly knew almost everything. (Some still claim it wasn’t Shakespeare who wrote those great works but no one else has been unequivocally identified as the author and, generally, it’s not that important an issue, except for scholars). In his plays we find history, geography, religion, the law, and the various sciences, including medicine.

In 1603, approximately fifty years after Eustachio (~1500-1574) described the anatomy of the auditory canal of the ear, Shakespeare told, in Hamlet, of murder by instilling poison in what is now called the Eustachian canal. In a related anatomic discovery, Eustachio’s contemporary, Fallopio (1523-1562), who described the uterine tube that still bears his name, was the first to describe the semicircular canals (semicircular ducts) of the ear, the site for origin of most vertigo cases. Although Shakespeare does not comment on the canals themselves, it would seem that he speaks about vertigo in Act I, Scene II of Romeo and Juliet, when Benvolio says

          Turn giddy, and be holp by backward turning 

         (translation expressly developed for this essay: If you have vertigo you’ll helped by changing the orientation of your semi-circular canals).

As we will see a particularly effective therapy for the most common form of vertigo is ‘backward turning:’ changing position to briefly re-orient each of the three semicircular canals. This method, credited to the distinguished 20th C otorhinolarungologist, John Epley, rather than Benvolio, can be quite successful.

The first modern description of vertigo, however, was almost four hundred years after Romeo and Juliet when, in 1897, a Dr. D. Adler (it has, thus far, not been possible to identify this Adler’s first name) of Breslau wrote Ubeden einseitengen Drehschwindel(very loosely translated as ‘about one-sided vertigo’). A quarter century later the article by Robert Bárány, of Upsala, Diagnose von krankheitserch-eingungen im mereich dedisorders of the vestibular apparatus of the ear otolithenappartes (even more loosely, ‘the diagnosis of symptomatic diseases of the semi-circular canals’) contributed considerably to our understanding of vertigo and similar conditions. Bárány was awarded a Nobel Prize and has come to be regarded as the founder of the modern study of these disorders; The Barany Society is the international society devoted to research in this field.

 

My vertigo began at the beginning of May, about the time we were all becoming numb to the idea of self-quarantine because of COVID-19. Two days before, and for unrelated reasons, my physician suggested increasing the dose of one of my medications. That night, when I lay down for sleep, the ceiling started spinning – I can think of no better way to describe it. I could visualize at least three ceilings and they seemed to be in a pattern of rotation. It was a startling and fascinating experience and I rose up and lay down again a few times to both confirm it was actually occurring and that I was observing it correctly. After repeating the process a few more times to study the sensation, thinking I might want to put it in a piece of writing, I decided to get some water. When I got out of bed to walk to the kitchen, the entire room reeled, this time without a distinct image, requiring me to grab a piece of furniture to maintain my balance.

Two things need to be understood at this point of the narrative:

  1. One of the first things I was taught in medical school was the old adage, “A doctor who treats himself has a fool for a patient.” I have always believed this to be true while regularly, along with most physicians, ignoring it.
  2. Pathologists, who know more about the bad things that can happen to a human being than anyone, almost always think of the worst possible outcomes long before considering the best when they or family members have a medical complaint.

So, as I am clutching at whatever I can find to keep my balance, I ask myself if it could be a brain tumor. Too many dear friends have, over the years, died of glioblastoma and other brain tumors, and I wondered if I was next. Without going into a long discussion about my reasoning at the time, I rapidly considered the typical symptoms and signs that could indicate some space-occupying lesion in my head and decided that diagnosis unlikely. My next question—by now the vertigo had abated—was: could it be from the increase of the dose of the medication? Easy to resolve in this modern world where Google, the world’s greatest library, available at your fingertips, can provide all answers. Lo and behold, that medication is associated with vertigo!

The next day an email to the physician who prescribed the drug and increased the dose confirmed the possibility. He advised stopping the medication for a while. In a few days I was scheduled to visit a neurologist for an unrelated matter and she carried out a variety of neurologic tests—she was able to provoke the rapid, involuntary repetitive motion of my eyes to one side (nystagmus)—and concluded I had “benign paroxysmal positional vertigo.” She recommended a series of ‘Epley exercises’ which exemplify Bonvolio’s advice. Three days later my vertigo was gone, providing another ‘lo and behold’ moment: “Google medicine” does not always help!!

What happens when you do the Epley exercises? A prevailing explanation for the onset of vertigo is that a tiny stone (“lithos” in Greek, as in cholelithiasis or gallstones), known in the ear as ‘otoconia,’ is displaced from its usual position (the ‘utricle’) in the inner ear and moves into, and obstructs, one of the semicircular canals preventing the shift of hydraulics necessary to maintain balance. Otoconia are small, highly dense calcific crystals exclusively associated with inner ear structures, including the utricle and the saccule. In mice, a genetic model was developed that leads to the formation of abnormally large calcium carbonate minerals with subsequent hearing loss and severe balance defects. In humans, the Epley maneuvers help move the otoconia (ear stones) from their abnormal position back to where they should be, allowing for the free flow of fluid in the semi-circular canals and the restoration of balance.

Revisiting the Hitchcock film reminded me that Jimmy Stewart’s character, the former police detective John (“Scotty”) Ferguson, has two potentially disabling disorders: he suffers from acrophobia (a severe fear of heights) as well as vertigo. Indeed, confronting heights provokes the vertigo. The rest of the story, with its typical Hitchcockian surprise, will not be divulged here – see the film. Twenty years after Vertigo was released, Mel Brooks, the comic genius who created The Producers, one of the funniest films ever made, parodied Vertigo in his satirical production, High Anxiety. Brooks’ protagonist’s name, Richard Thorndyke, is clearly, and most likely deliberately, reminiscent of the main character in Hitchock’s other great film, North by Northwest, Roger Thornhill.

What precipitated my vertigo? I also have, for about ten years, a mild form of hyperparathyroidism (increased activity of the parathyroid glands, one of the functions of which is to regulate calcium metabolism). Could I have had a sudden burst of parathyroid activity with subsequent increase of  calcium levels (‘hypercalcemia’) depositing on, and causing enlargement of, those tiny grains of sand. That is unlikely since a recent blood calcium determination was unchanged. More importantly, four months later, I remain happily free of vertigo, still taking the same medicines I was taking before it developed and without the development of any other troublesome signs or symptoms.

Moses Wharton Young, M.D., Ph.D. taught neuroanatomy to my medical school class. He was a pioneering investigator of the anatomy of the ear. He simplified a known technique and gently forced metals with low melting point into the inner ear portion of the temporal bone of cadavers from which all soft tissues had been chemically removed. With this method he was able to demonstrate the inner ear labyrinth, discovering the endolymphatic duct (ductus endolymphaticus; Wharton duct), which can also be seen in the diagram above. He typically wore a tie-pin of the semicircular canals created with the same technique. Sadly, Young’s story is a vivid example of institutional racism. As one of many examples, his work was ignored, despite being published in highly reputable journals and, for a time, others received He was a brilliant and highly entertaining teacher and I vividly remember that the first neuroanatomy lecture when he introduced the subject by saying that learning neuroanatomy was as easy as A, B, C. It took me very little time to realize that, at least for me, that was not true.

Although my vertigo is happily just a memory I now share a newly common disorder with almost everyone: ‘cabin fever.’ I mostly keep busy with writing, reading, movies I would never have seen otherwise, two-and-a-half-mile walks and active correspondence (emails, occasional forays into Facebook and even some old-fashioned hand-written notes). It is likely that we will remain mostly isolated until early 2021. In order to combat the ennui, Kate and I recently started a 1000-piece jigsaw puzzle of van Gogh’s Starry Night, clear evidence of the need for diversion as well as of a not completely latent tendency for masochism.